HB5407 Engrossed LRB096 17948 RPM 33316 b

1     AN ACT concerning insurance.
 
2     Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
 
4     Section 5. The Illinois Insurance Code is amended by
5 changing Section 356w as follows:
 
6     (215 ILCS 5/356w)
7     Sec. 356w. Diabetes self-management training and
8 education.
9     (a) A group policy of accident and health insurance that is
10 amended, delivered, issued, or renewed after the effective date
11 of this amendatory Act of 1998 shall provide coverage for
12 outpatient self-management training and education, equipment,
13 and supplies, as set forth in this Section, for the treatment
14 of type 1 diabetes, type 2 diabetes, and gestational diabetes
15 mellitus.
16     (b) As used in this Section:
17     "Diabetes self-management training" means instruction in
18 an outpatient setting which enables a diabetic patient to
19 understand the diabetic management process and daily
20 management of diabetic therapy as a means of avoiding frequent
21 hospitalization and complications. Diabetes self-management
22 training shall include the content areas listed in the National
23 Standards for Diabetes Self-Management Education Programs as

 

 

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1 published by the American Diabetes Association, including
2 medical nutrition therapy.
3     "Medical nutrition therapy" shall have the meaning
4 ascribed to "medical nutrition care" in the Dietetic and
5 Nutrition Services Practice Act.
6     "Physician" means a physician licensed to practice
7 medicine in all of its branches providing care to the
8 individual.
9     "Qualified provider" for an individual that is enrolled in:
10         (1) a health maintenance organization that uses a
11     primary care physician to control access to specialty care
12     means (A) the individual's primary care physician licensed
13     to practice medicine in all of its branches, (B) a
14     physician licensed to practice medicine in all of its
15     branches to whom the individual has been referred by the
16     primary care physician, or (C) a certified, registered, or
17     licensed network health care professional with expertise
18     in diabetes management to whom the individual has been
19     referred by the primary care physician.
20         (2) an insurance plan means (A) a physician licensed to
21     practice medicine in all of its branches or (B) a
22     certified, registered, or licensed health care
23     professional with expertise in diabetes management to whom
24     the individual has been referred by a physician.
25     (c) Coverage under this Section for diabetes
26 self-management training, including medical nutrition

 

 

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1 education, shall be limited to the following:
2         (1) Up to 3 medically necessary visits to a qualified
3     provider upon initial diagnosis of diabetes by the
4     patient's physician or, if diagnosis of diabetes was made
5     within one year prior to the effective date of this
6     amendatory Act of 1998 where the insured was a covered
7     individual, up to 3 medically necessary visits to a
8     qualified provider within one year after that effective
9     date.
10         (2) Up to 2 medically necessary visits to a qualified
11     provider upon a determination by a patient's physician that
12     a significant change in the patient's symptoms or medical
13     condition has occurred. A "significant change" in
14     condition means symptomatic hyperglycemia (greater than
15     250 mg/dl on repeated occasions), severe hypoglycemia
16     (requiring the assistance of another person), onset or
17     progression of diabetes, or a significant change in medical
18     condition that would require a significantly different
19     treatment regimen.
20     Payment by the insurer or health maintenance organization
21 for the coverage required for diabetes self-management
22 training pursuant to the provisions of this Section is only
23 required to be made for services provided. No coverage is
24 required for additional visits beyond those specified in items
25 (1) and (2) of this subsection.
26     Coverage under this subsection (c) for diabetes

 

 

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1 self-management training shall be subject to the same
2 deductible, co-payment, and co-insurance provisions that apply
3 to coverage under the policy for other services provided by the
4 same type of provider.
5     (d) Coverage shall be provided for the following equipment
6 when medically necessary and prescribed by a physician licensed
7 to practice medicine in all of its branches. Coverage for the
8 following items shall be subject to deductible, co-payment and
9 co-insurance provisions provided for under the policy or a
10 durable medical equipment rider to the policy:
11         (1) blood glucose monitors;
12         (2) blood glucose monitors for the legally blind;
13         (3) cartridges for the legally blind; and
14         (4) lancets and lancing devices.
15     This subsection does not apply to a group policy of
16 accident and health insurance that does not provide a durable
17 medical equipment benefit.
18     (e) Coverage shall be provided for the following
19 pharmaceuticals and supplies when medically necessary and
20 prescribed by a physician licensed to practice medicine in all
21 of its branches. Coverage for the following items shall be
22 subject to the same coverage, deductible, co-payment, and
23 co-insurance provisions under the policy or a drug rider to the
24 policy:
25         (1) insulin;
26         (2) syringes and needles;

 

 

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1         (3) test strips for glucose monitors;
2         (4) FDA approved oral agents used to control blood
3     sugar; and
4         (5) glucagon emergency kits; and .
5         (6) the treatment of pain associated with
6     complications of diabetes.
7     This subsection does not apply to a group policy of
8 accident and health insurance that does not provide a drug
9 benefit.
10     (f) Coverage shall be provided for regular foot care exams
11 by a physician or by a physician to whom a physician has
12 referred the patient. Coverage for regular foot care exams
13 shall be subject to the same deductible, co-payment, and
14 co-insurance provisions that apply under the policy for other
15 services provided by the same type of provider.
16     (g) If authorized by a physician, diabetes self-management
17 training may be provided as a part of an office visit, group
18 setting, or home visit.
19     (h) This Section shall not apply to agreements, contracts,
20 or policies that provide coverage for a specified diagnosis or
21 other limited benefit coverage.
22 (Source: P.A. 90-741, eff. 1-1-99.)